INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 1, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Davis Archway Treatment Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the personnel training records, the facility failed to have the counselor complete at least 25 clock hours of annual training in one of one applicable record.
Employee #2 was hired as a counselor on March 3, 2023. Employee #2 documented 10 hours of training for the July 1, 2023 to June 30, 2024 training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director has taken steps to ensure clinical team members are following their training plan and keeping up to date on training hours. The Clinical Director has met with each counselor to review their plan for obtaining the required hours. The plan of correction will be monitored during individual supervision sessions to ensure compliance. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the administrative information, the facility failed to document a policy and procedure for notifying the emergency contact for clients who discharge against facility advice in the detoxification level of care.
Client #3 was admitted to the detoxification level of care on August 4, 2024, and discharged against facility advice on August 8, 2024. There was no documentation of an attempt to contact the emergency contact.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The CEO met with the Director of Nursing and the counselor assigned to detox and instructed them to document communication with the EC in the discharge note for all clients who leave against facility advice. The CEO also wrote the policy in the detox policy manual outlining the steps to take to notify the emergency contact. The plan will be monitored by the CEO to ensure contact is made with the EC. |
709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of client records, the facility failed to notify the emergency contact of a client's decision to leave against facility advice in one of one applicable record.
The facility's inpatient non-hospital residential policy and procedure manual states the client ' s emergency contact will be notified of the client ' s decision to leave against facility advice.
Client #10 was admitted to the residential level of care on May 14, 2024, and discharged on June 22, 2024.
There was a consent for the emergency contact in client #10 ' s record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
THe CEO met with the Clinical Director and clinical team members and reviewed the policy for contacting the EC when clients leave against facility advice. Staff have been reminded to document attempts made in the discharge note. This plan will be monitored by the CEO and Clinical Director for compliance. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan in five of seven applicable records.
The facility ' s policy and procedure manual states the comprehensive treatment plan must be completed between within 7 days following admission.
Client #9 was admitted to the residential level of care on November 14, 2023, and discharged on February 13, 2024. A comprehensive treatment plan was due no later than November 21, 2024; however, it was not completed until November 25, 2024.
Client #10 was admitted to the residential level of care on May 14, 2024, and discharged on June 22, 2024. A comprehensive treatment plan was due no later than May 21, 2024; however, it was not completed until May 22, 2024.
Client #11 was admitted to the residential level of care on June 19, 2024, and discharged on June 29, 2024. A comprehensive treatment plan was due no later than June 26, 2024; however, it was not completed until June 27, 2024.
Client #13 was admitted to the residential level of care on September 16, 2024, and was still an active client at the time of the inspection. A comprehensive treatment plan was due no later than September 23, 2024; however, it was not completed until September 25, 2024.
Client #14 was admitted to the residential level of care on September 18, 2024, and was still an active client at the time of the inspection. A comprehensive treatment plan was due no later than September 25, 2024; however, it was not completed until October 1, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The CEO and Clinical Director met with the clinical team and reviewed the timeframe for completion of the comprehensive treatment plan. The facility is utilizing tools within the EHR to notify the staff member of due dates for documentation, while the daily list is reviewed with the clinical team by the Clinical Director during the daily clinical team meeting. This plan will be monitored by the Clinical Director to ensure compliance. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates every 15 days as per their policy in four of four applicable records.
Client #8 was admitted to the residential level of care on November 30, 2023, and discharged on January 6, 2024. A treatment plan was completed on December 7, 2023, and an update was due no later than December 22, 2023; however, it was completed on January 6, 2024.
Client #9 was admitted to the residential level of care on November 14, 2023, and discharged on February 13, 2024. A treatment plan was completed on November 25, 2023, and an update was due no later than December 10, 2023; however, it was completed on December 21, 2023. The next update was due no later than January 5, 2024; however, it was completed on January 13, 2024. The next update was due no later than January 28, 2024; however, there were no further updates in client #9 ' s record.
Client #10 was admitted to the residential level of care on May 14, 2024, and discharged on June 22, 2024. A treatment plan was completed on May 22, 2024, and an update was due no later than June 6, 2024; however, it was completed on June 20, 2024.
Client #12 was admitted to the residential level of care on August 8, 2024, and was still an active client at the time of the inspection. A treatment plan was completed on August 8, 2024, and an update was due no later than August 23, 2024; however, there were no further updates in client #12 ' s record.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the September 20, 2023 licensing inspection.
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Plan of Correction
The CEO and Clinical Director met with the clinical team and reviewed the timeframe for completion of the treatment plan update. The facility is utilizing tools within the EHR to notify the staff member of due dates for documentation, while the daily list is reviewed with the clinical team by the Clinical Director during the daily clinical team meeting. This plan will be monitored by the Clinical Director to ensure compliance. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in three of six applicable records.
The facility's policy and procedure manual states a case consultation must be completed within 7 days of admission then every 15 days.
Client #8 was admitted to the residential level of care on November 30, 2023, and discharged on January 6, 2024. There were no case consults in client #8 ' s record.
Client #10 was admitted to the residential level of care on May 14, 2024, and discharged on June 22, 2024. There were no case consults in client #10 ' s record.
Client #12 was admitted to the residential level of care on August 8, 2024, and was still an active client at the time of the inspection. There was a case consult on August 15 and no further case consults in client #12 ' s record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The CEO and Clinical Director met with the clinical team and reviewed the timeframe for completion of the client case consultation. The facility is utilizing tools within the EHR to notify the staff member of due dates for documentation, while the daily list is reviewed with the clinical team by the Clinical Director during the daily clinical team meeting. This plan will be monitored by the Clinical Director to ensure compliance. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in three of four applicable discharged records.
Client #8 was admitted to the residential level of care on November 30, 2023, and discharged on January 6, 2024. There was no discharge summary in client #8 ' s record.
Client #10 was admitted to the residential level of care on May 14, 2024, and discharged on June 22, 2024. There was no discharge summary in client #10 ' s record.
Client #11 was admitted to the residential level of care on June 19, 2024, and discharged on June 29, 2024. There was no discharge summary in client #11 ' s record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Director will conduct weekly chart audits for all discharged clients to ensure the discharge summary is completed for each client record. As well, the facility is utilizing the EHR notifications for when the document needs to be completed. This plan will be monitored by the Clinical Director to ensure compliance. |